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Current guidelines for neurogenic bladder (NGB) contain contrasting recommendations in several areas. In this review, the current literature published over the last 5 years will be critically evaluated. A number of novel techniques and therapeutic agents have been introduced in the past 5 years or are currently under investigation. Current guidelines do not take these into account. Mirabegron, electromotive onabotulinumtoxin, hydrogel onabotulinumtoxin, progress in neuromodulation (laparoscopic lead implantation, utility in acute and incomplete spinal cord injury (SCI), transrectal neurostimulation, rechargeable MRI-compatible leads and devices), minimally invasive technique and tissue engineering for augmentation cystoplasty (AC), and risk-based surveillance are few of the recent developments in this field. NGB is a major global medical and social problem. Many international guidelines are available to assist the clinician to provide best treatment to this patient population. Many of the guidelines, however, have not been updated and do not take into account new developments. Newer drugs and techniques described in the literature over the last 5 years should influence the established guidelines. It may be time to update some existing guidelines.

Aim Female urethral stricture disease is rare and has several surgical approaches including endoscopic dilations (ENDO), urethroplasty with local vaginal tissue flap (ULT) or urethroplasty with free graft (UFG). This study aims to describe the contemporary management of female urethral stricture disease and to evaluate the outcomes of these three surgical approaches. Methods This is a multi-institutional, retrospective cohort study evaluating operative treatment for female urethral stricture. Surgeries were grouped into three categories: ENDO, ULT, and UFG. Time from surgery to stricture recurrence by surgery type was analyzed using a Kaplan-Meier time to event analysis. To adjust for confounders, a Cox proportional hazard model was fit for time to stricture recurrence. Results Two-hundred and ten patients met the inclusion criteria across 23 sites. Overall, 64% (n = 115/180) of women remained recurrence free at median follow-up of 14.6 months (IQR, 3-37). In unadjusted analysis, recurrence-free rates differed between surgery categories with 68% ENDO, 77% UFG and 83% ULT patients being recurrence free at 12 months. In the Cox model, recurrence rates also differed between surgery categories; women undergoing ULT and UFG having had 66% and 49% less risk of recurrence, respectively, compared to those undergoing ENDO. When comparing ULT to UFG directly, there was no significant difference of recurrence. Conclusion This retrospective multi-institutional study of female urethral stricture demonstrates that patients undergoing endoscopic management have a higher risk of recurrence compared to those undergoing either urethroplasty with local flap or free graft.

The opioid epidemic has become a major public health crisis over the last two decades. The opioid-related deaths and economic costs have increased dramatically since opioid analgesics started to be prescribed regularly to help control cancer- and non-cancer-related pain in the late twentieth century. As a result of the worsening opioid crisis, various guidelines and government regulations have recently been implemented to cope with this opioid problem as it affects all fields of medicine, urology included. Many conditions in urology involve chronic pain medication, including neurogenic bladder. This review seeks to summarize the growing problem of opioid use and prescribing practices nationwide. Specifically to urology, there is a growing body of literature that could aid urologists in creating good practices and guidelines to improve safety for patients requiring narcotic medications to increase awareness of new legal requirements and utilization of multimodal and alternative therapies post-operative, acute pain as well as chronic pain. The CDC has published 12 guidelines that have been used to frame state-specific chronic opioid prescribing guidelines and laws nationwide. Moreover, many states have enacted laws regulating the use of opioids and in some cases penalizing physicians for non-compliance. Specific to urology, studies have demonstrated unfilled opioid prescriptions after urologic procedures, considerable variability in the prescribing habits, and low rates of opioid dependency after prescription for acute post-operative pain. Urologists and all physicians are increasingly under the microscope for opioid prescribing practices and need to understand current guidelines and literature.

INTRODUCTION AND OBJECTIVE:Diabetes (DM) affects 34.2 million Americans.1 Diabetic bladder dysfunction is thought to affect approximately 25-50% of patients with Type 2 diabetes and is classically ...

Introduction There is a paucity of patient reported outcome measure (PROM) data for women with urethral strictures. To address this gap, we aim to evaluate change in PROM among women who underwent surgery for a stricture. Methods American Urological Association Symptom Index (AUA-SI) and Urogenital Distress Inventory (UDI-6) data from a multi-institutional retrospective cohort study of women treated for urethral stricture was assessed. Results Fifty-seven women had either AUA-SS or UDI-6 and 26 had baseline and postoperative data for either. Most women underwent urethroplasty (77%) and the majority (73%) remained stricture free at median follow-up of 21 months (interquartile range [IQR] 7-37). The median baseline AUA-SI was 21 (IQR 12-28) and follow-up was 10 (IQR 5-24). After treatment, there was a median decrease of 12 (IQR -18 to -2) in AUA-SI (p = 0.003). The median AUA Quality of life (QOL) score at baseline and follow-up were 6 (IQR 4-6) and 3 (IQR 2-5), respectively. There was a median AUA-QOL improvement of 2 points (-5,0; p = 0.007) from a baseline 5 (unhappy) to 3 (mixed). Median UDI-6 scores were 50 (IQR 33-75) at baseline and 17 (IQR 0-39), at follow-up. After treatment, there was a median decrease of 19 (-31 to -11; p = 0.01). Conclusion Women with urethral strictures have severe lower urinary tract symptoms which improved after surgery. This study substantiates the claims that recognizing and treating women with urethral stricture disease greatly improves lower urinary tract symptoms and QOL.

Objective: The objective is to compare robotic sacral colpopexy (RSC) utilizing autologous fascia lata with RSC with synthetic mesh in the treatment of pelvic organ prolapse (POP). Methods: We perf...

Metabolic Syndrome (MetS) has detrimental effects on the bladder, including detrusor underactivity. The progression and mechanism of disease are poorly understood. A swine model for diabetic bladder dysfunction (DBD) was established because of the pig's human-sized bladder and its ability to develop MetS by dietary modification alone. The hypothesis of this study is that this swine model will demonstrate oxidative stress associated with MetS, which contributes to both bladder fibrosis and detrusor underactivity (DU). Ossabaw pigs underwent dietary modification consisting of a hypercaloric, atherogenic diet for 10 mo to induce MetS, and were compared with a group of control (lean) pigs. Urodynamic studies were performed in both groups to confirm DU. Thiobarbituric acid reactive substances (TBARS) detected in the urine were used to measure oxidative stress activity in the urinary tract, and urinary IL17a was used to detect profibrotic activity. MetS was confirmed by assessing body weight, blood pressure, glucose tolerance, total cholesterol, and triglycerides. The MetS group exhibited an increase in the relative levels of urinary TBARS and IL17a. Bladder pressures at capacity were lower in the MetS group, suggesting DU. Histologic analysis of a cohort of control (lean) and MetS pigs revealed that as compared with the control pigs, the MetS pigs had significantly more collagen in the muscularis layer, but not in the submucosa or mucosa layer. In conclusion, the Ossabaw pig model for diet-induced MetS is associated with oxidative stress and profibrotic activity in the bladder, which results in DU. This has previously been shown in mice and rats, but never in pigs. This novel model will better represent human MetS and DBD because the mechanism and size of the pig bladder more closely resemble that of a human, resulting in a more valid model and facilitating further study into the signaling mechanisms responsible for this impairment.

The purpose this manuscript is to describe the work of one program in Kenya, East Africa, to train general surgery residents in urology to make available the much needed service to the underserved rural population. People in developing countries continue to face the challenge of accessing surgical care with a ratio of 1 surgeon to 20,000 people. This is due, in part, to the inadequate number of trained surgeons. The availability of specialized surgical care such as urology is even more unlikely due to fewer numbers of specialists in urology. Such disciplines take many years of training before a person qualifies as a specialist. This requires highly motivated and suitable candidates who are willing to spend time in training and acquiring skills as well as proper infrastructure for training. There is an effort to train general surgical residents in enhanced skills to make available urology services to the wider population. This involves equipping them with skills in general urology, basic skills in handling endoscopic equipment, and basic endo-urology procedures such as diagnostic cystoscopy with or without biopsy and direct vision urethrotomy (DVU). The residents are also exposed to visiting faculty through international collaborations, surgical camps, and workshops to enhance their skills and knowledge. Equipping general surgical residents with urology skills will greatly reduce the shortage of these services to the people of developing countries.

Background Carcinoma in situ (CIS) is a poor prognostic finding in urothelial carcinoma. However, its significance in muscle-invasive urothelial carcinoma (MIUC) treated with neoadjuvant chemotherapy (NAC) is uncertain. We assessed the effect of CIS found in pretreatment transurethral resection of bladder tumor (TURBT) biopsies on the pathologic and clinical outcomes. Materials and Methods Subjects with MIUC treated with NAC before cystectomy were identified. The pathologic complete response (pCR) rates stratified by TURBT CIS status were compared. The secondary analyses included tumor response, progression-free survival (PFS), overall survival (OS), and an exploratory post hoc analysis of patients with pathologic CIS only (pTisN0) at cystectomy. Results A total of 137 patients with MIUC were identified. TURBT CIS was noted in 30.7% of the patients. The absence of TURBT CIS was associated with a significantly increased pCR rate (23.2% vs. 9.5%; odds ratio, 4.08; 95% confidence interval, 1.19-13.98; P = .025). Stage pTisN0 disease was observed in 19.0% of the TURBT CIS patients. TURBT CIS status did not significantly affect the PFS or OS outcomes. Post hoc analysis of the pTisN0 patients revealed prolonged median PFS (104.5 vs. 139.9 months; P = .055) and OS (104.5 vs. 152.3 months; P = .091) outcomes similar to those for the pCR patients. Conclusion The absence of CIS on pretreatment TURBT in patients with MIUC undergoing NAC was associated with increased pCR rates, with no observed differences in PFS or OS. Isolated CIS at cystectomy was frequently observed, with lengthy PFS and OS durations similar to those for pCR patients. Further studies aimed at understanding the biology and clinical effect of CIS in MIUC are warranted.

Introduction and Objective: Nonabsorbable monofilament suture is traditionally used to secure vaginal mesh for robot-assisted sacral colpopexy (RASC) but can become exposed postoperatively requirin...

Diabetes can often cause lower urinary tract symptom (LUTS). This has been called diabetic cystopathy by many authors, but no concise grouping of symptoms for this condition has been agreed upon. The etiology of diabetic cystopathy remains unknown, but evidence from the literature strongly suggests a neurologic etiology as the primary factor, with other factors such as polyuria, damage to muscle from oxidative stress, and urothelial factors possibly contributing. Once a standard definition for diabetic cystopathy can be agreed upon, prospective, longitudinal studies will play a key role in the generation of hypotheses for the causes of diabetic cystopathy. Animal models will help test these hypotheses and possibly provide strategies for prevention.

Introduction Female urethral stricture is rare and decreases quality of life. Buccal mucosa has become the most popular graft material for male urethroplasty but little is written about females. Rare case reports of buccal mucosa grafting in the female appear in the literature as an alternate method to more commonly performed vaginal flap urethroplasty (Blandy-style flap) or free vaginal mucosa graft urethroplasty. The hypothesis is that dorsal onlay buccal mucosa grafting will improve quality of life scores and provide acceptable recurrence-free rates. Methods We compiled a retrospective case series from 2009 to 2013 to identify female patients treated with dorsal onlay buccal urethroplasty via a suprameatal approach. All patients underwent pelvic exam as well as a supine stress test. Study end points included stricture recurrence verified by cystoscopy, uroflow, post-void residual urine, presence of urinary tract infection, pain, fistula formation, incontinence, and complications at the donor site and the vagina. Results Six patients were identified. Mean followup was 18.6 months. No stress incontinence was noted preoperatively and none developed postoperatively. No fistulas were noted. Mean stricture length was 1.2 cm and mean graft length was 2.75 cm. Two stricture recurrences (33%) were noted, requiring dilation. Mean pain score went from 7.2 to 0 on a 10-point Likert scale (p = 0.004). The number of urinary tract infections per year decreased from 4.3 to 0.3 (p = 0.038). Maximum voided velocity increased from 5.6 to 13.1 ml per second (p = 0.003) and mean post-void residual urine decreased from 270 to 34 ml (p = 0.094). No urethral or vaginal complications were reported. Two patients reported donor site morbidity but no clitoral anesthesia or pain was reported. Conclusions Dorsal onlay buccal urethroplasty provided acceptable but not improved cure rates compared with the published failure rates of alternative methods. Patients experienced significant improvements in pain, urinary flow and quality of life. It can be safely considered instead of ventral onlay vaginal flap urethroplasty or serial dilation in females with stricture.

Sacral neuromodulation has had a tremendous impact on the treatment of urinary incontinence and lower urinary tract symptoms for patients with neurologic conditions. This stimulation does not use real-time data from the body or input from the patient. Incorporating this is the goal of those pursuing a neuroprosthesis to enhance bladder function for these patients. Investigators have demonstrated the effectiveness of conditional (also called closed-loop) feedback in animal models as well as limited human studies. Dorsal genital nerve, pudendal nerve, S3 afferent nerve roots, S1 and S2 ganglia have all been used as targets for stimulation. Most of these have also been used as sources of afferent nerve information using sophisticated nerve electrode arrays and filtering algorithms to detect significant bladder events and even to estimate the fullness of the bladder. There are problems with afferent nerve sensing, however. Some of these include sensor migration and low signal to noise ratios. Implantable pressure sensors have also been investigated that have their own unique challenges, such as erosion and sensor drift. As technology improves, an intelligent neuroprosthesis with the ability to sense significant bladder events and stimulate as needed will evolve.

Purpose of Review Sacral neuromodulation (SNM) is being used to treat lower urinary tract symptoms (LUTS) with growing popularity among clinicians in multiple specialties. As this therapy becomes more common in the USA and Europe, urologists will encounter more patients implanted with SNM generators. Recent Findings Over time, it has recently been understood that up to 53% will develop pain at the implant site as reported by Groen et al. (J Urol 186:954, 2011) and 3–38% will lose effective stimulation as reported by Al-zahrani et al. (J Urol 185:981, 2011) and White et al. (Urology 73:731, 2009). There is a paucity of troubleshooting methodology in the literature, apart from revision surgery, to salvage the SNM generator. In fact, it has been suggested that one contemporary series’ failure rate is lower than some historic series because of the ability to reprogram devices as reported by Siegel et al. (J Urol 199:229, 2018). Standard algorithms for such reprogramming efforts are lacking in the literature and may salvage some patients otherwise destined for surgical revision or addition of multimodal therapy to achieve acceptable symptom control. Summary It is possible to troubleshoot and thereby salvage many SNM generators, saving patients from surgical revision in many cases and increasing the number of patients with persistent benefit from SNM. The algorithms presented in this manuscript represent a systematic strategy for reprogramming and troubleshooting SNM generators.

Robot-assisted sacral colpopexy (RASC) is a fast growing approach for surgeons treating patients with advanced stage pelvic organ prolapse (POP). Open abdominal sacral colpopexy has been the gold standard for advanced POP but requires longer hospital stays and a much larger incision. The indications, preoperative preparation, operative positioning, and operative steps are detailed, and an accompanying video shows the approach.RASC can be broken down into 11 steps and the reader will be able to reference the article to the corresponding portion of the video.A total of 119 women underwent RASC between 2009 and 2016. Patients had similar preoperative characteristics. All POP-Q, UDI-6, and quality of life scores improved postoperatively. Apical failure was noted in 0, anterior failure was noted in 7 (average Ba +1.1 cm in failures), and posterior failure was noted in 4 (mean Bp +1.0 cm) patients at 15.6 months' follow-up. A total of 11 suture erosions were noted in five patients requiring excision in the clinic and 2 patients in the operating room. Four suture erosions were managed with observation. Two mesh exposure events were noted.Outcomes for robotic sacral colpopexy are like those of open abdominal sacral colpopexy.

Overactive bladder (OAB) affects millions of people around the world and decreases quality of life for those affected. Over the past two decades, significant advances in treatment have transformed the lives of those with OAB. Sacral neuromodulation (SNM), posterior tibial nerve stimulation (PTNS), and dorsal genital nerve stimulation are the most effective contemporary treatment modalities. New techniques and bio-sensing schemes offer promise to advance therapy beyond what is currently available. Current neuromodulation techniques do not use real-time data from the body or input from the patient. Incorporating this is the goal of those pursuing a neuroprosthesis to enhance bladder function for these patients. Dorsal genital nerve, pudendal nerve, S3 afferent nerve roots, and S1 and S2 ganglia have all been used as targets for stimulation. Some of these have also been used as sources of afferent nerve information to detect significant bladder events and even to estimate the fullness of the bladder. As technology improves, an intelligent neuroprosthesis with the ability to sense significant bladder events may revolutionize treatment of OAB.

Although neuromodulation is well established for the treatment of non-neurogenic lower urinary tract symptoms, recent literature supports its use in the patient having LUTS associated with a neurologic condition. Sacral neuromodulation, in particular, may see new use as a modality to facilitate neurologic remodeling in spinal cord injured patients as well as children. As a therapeutic option, sacral neuromodulation and dorsal genital nerve stimulation may one day become more effective and more efficient utilizing the concept of closed-loop feedback, where electro-neurogram and bladder pressure data are incorporated into stimulation routines. In addition, some older therapies are reviewed that have recently demonstrated success in this patient population.

Monitoring bodily pressures provide valuable diagnostic and prognostic information. In particular, long-term measurement through implantable sensors is highly desirable in situations where percutaneous access can be complicated or dangerous (e.g., intracranial pressure in hydrocephalic patients). In spite of decades of progress in the fabrication of miniature solid-state pressure sensors, sensor drift has so far severely limited their application in implantable systems. In this paper, we report on a universal packaging technique for reducing the sensor drift. The described method isolates the pressure sensor from a major source of drift, i.e., contact with the aqueous surrounding environment, by encasing the sensor in a silicone-filled medical-grade polyurethane balloon. In-vitro soak tests for 100 days using commercial micromachined piezoresistive pressure sensors demonstrate a stable operation with the output remaining within 1.8 cmH2O (1.3 mmHg) of a reference pressure transducer. Under similar test conditions, a non-isolated sensor fluctuates between 10 and 20 cmH2O (7.4-14.7 mmHg) of the reference, without ever settling to a stable operation regime. Implantation in Ossabow pigs demonstrate the robustness of the package and its in-vivo efficacy in reducing the baseline drift.

Overactive bladder is a significant health problem for individuals of all ages. Posterior tibial nerve stimulation for overactive bladder is not a new concept, but providers and some third party payers have been slow to embrace it. Until recently, lack of level 1 evidence had raised questions as to its efficacy and duration of benefit. Level 1 evidence now exists to support its use for the treatment of overactive bladder. However, questions remain as to the durability of the benefit. It is likely that chronic maintenance therapy will be necessary in most cases. Emerging evidence may expand the indications for posterior tibial nerve stimulation to include multiple sclerosis, Parkinson’s disease, childhood voiding dysfunction, fecal incontinence, interstitial cystitis, and chronic prostatitis. New methods for stimulating this nerve without needles may someday replace current techniques.

Terrorist attacks involving radiological or nuclear weapons are a substantial geopolitical concern, given that large populations could be exposed to potentially lethal doses of radiation. Because of this, evaluating potential countermeasures against radiation-induced mortality is critical. Gut microflora are the most common source of systemic infection following exposure to lethal doses of whole-body radiation, suggesting that prophylactic antibiotic therapy may reduce mortality after radiation exposure. The chemical stability, easy administration and favorable tolerability profile of the non-systemic antibiotic, rifaximin, make it an ideal potential candidate for use as a countermeasure. This study evaluated the use of rifaximin as a countermeasure against low-to-intermediate-dose whole-body radiation in rodents. Female Wistar rats (8 weeks old) were irradiated with 550 cGy to the whole body and were evaluated for 30 d. Animals received methylcellulose, neomycin (179 mg/kg/d) or variably dosed rifaximin (150–2000 mg/kg/d) one hour after irradiation and daily throughout the study period. Clinical assessments (e.g. body weight) were made daily. On postirradiation day 30, blood samples were collected and a complete blood cell count was performed. Animals receiving high doses of rifaximin (i.e. 1000 or 2000 mg/kg/d) had a greater increase in weight from the day of irradiation to postirradiation day 30 compared with animals that received placebo or neomycin. For animals with an increase in average body weight from irradiation day within 80–110% of the group average, methylcellulose rendered an absolute neutrophil count (ANC) of 211, neomycin rendered an ANC of 334, rifaximin 300 mg/kg/d rendered an ANC of 582 and rifaximin 1000 mg/kg/d rendered an ANC of 854 ( P = 0.05 for group comparison). Exposure to rifaximin after near-lethal whole-body radiation resulted in diminished levels of neutropenia.

Bladder diverticula are common enough to be encountered by most urologists in practice but are reported less frequently in the literature than they were 50 years ago. Some patients can be managed nonoperatively, whereas others will need surgical intervention consisting of bladder outlet reduction and possibly removal of the diverticulum itself. In addition to the decision to operate, the timing of each intervention deserves careful consideration. Cystoscopy, computed tomography with contrast, urodynamic studies, cytology, and voiding cystourethrography play important roles in informing the clinician. Many new techniques for treatment of the bladder outlet and the diverticulum are available, such as laparoscopy and robotic surgery.

Aims We compared success rates, subsequent complications, and possible indications for success of sacral neuromodulation (SNM) for urinary voiding dysfunction in diabetic and non-diabetic patients. Methods Thirty-two diabetic patients (mean age 61.8 years, range 27-83) with urge incontinence, urgency-frequency syndrome, and/or urinary retention refractory to non-surgical treatment were retrospectively evaluated along with 211 non-diabetic patients (mean age 54.1 years, range 20-86) with similar symptoms. All patients who experienced >or=50% reduction in urinary symptoms following a 7- to 21-day test period went on to permanent SNM device implantation. Results No significant difference was found with respect to successful conversion rates from the test period to permanent implantation between diabetic and non-diabetic patients. Long-term success rates at a mean followup of 29.3 months following permanent device implantation for diabetic patients were 69.2% of those with urge incontinence, 85.7% of those with urgency-frequency, and 66.7% of those with urinary retention. The non-diabetic cohort had success rates of 67.0% for urge incontinence, 67.8% for urgency/frequency, and 58.2% for urinary retention (P = 0.823, 0.157, and 0.631, respectively). No patient experienced intraoperative complications. Nine of 24 (37.5%) devices were explanted postoperatively in diabetic patients compared with 36 of 141 (25.5%) in non-diabetic patients (P = 0.224). The number of explants due to infection was higher in diabetic patients (16.7%) versus non-diabetic patients (4.3%; P = 0.018). Conclusions No difference in long-term success rates was seen in diabetic patients when compared with similar, non-diabetic patients. Diabetic patients did, however, have a higher incidence of device explantation due to infection.

Psychological stress has long been suspected to worsen voiding dysfunction in men, but the possible causal relationship is poorly understood. Investigators have used many study methods, including observational studies and several prospective trials, intended to elicit psychological stress and then measure symptoms. Prostate growth is noted to decrease in animals that have undergone surgical sympathectomy, suggesting a role for the sympathetic nervous system in the growth of the prostate and not just in the contraction of its smooth muscle component. Prostate-specific antigen is noted to increase in men with poor social support and recent stress. Voiding parameters and prostate volume are also affected in patients with spinal cord injury. A growing body of literature relates stress to voiding dysfunction. Interest in this will likely increase as the knowledge base and understanding of the physiology improve.

Costs of neurogenic bladder vary widely and depend on a number of factors including severity of disease, symptomatology, patient insurance, and devices required. Recognition of how each treatment strategy will impact the patient financially could help guide selection of treatment as well as improve compliance with the chosen regimen. We have attempted to provide an overview of long-term cost considerations for the neurogenic bladder patient. Armed with this information, the practitioner can better help the patient select a bladder care regimen that balances the desire to both minimize symptoms now and preserve urinary tract integrity for the future, yet still remain cost-effective.

The observation that men with sperm density greater than 10 million/ml had low probability of endocrinopathy led to a refinement in the evaluation of subfertility. Using statistical methods, we sought to provide a more accurate prediction of which patients have an endocrinopathy, and to report the outcome as the odds of having disease. In addition, by examining the parameters that influenced the model significantly, the underlying pathophysiology might be better understood. Records of 1035 men containing variables including testis volume, sperm density, motility as well as the presence of endocrinopathy were randomized into 'training' and 'test' data sets. We modeled the data set using linear and quadratic discriminant function analysis, logistic regression (LR) and a neural network. Wilk's regression analysis was performed to determine which variables influenced the model significantly. Of the four models investigated, LR and a neural network performed the best with receiver operating characteristic areas under the curve of 0.93 and 0.95, respectively, correlating to a sensitivity of 28% and a specificity of 99% for the LR model, and a sensitivity and specificity of 56 and 97% for the neural network model. Reverse regression yielded P-values for the testis volume and sperm density of

This paper reports on a generic packaging method for reducing drift in implantable pressure sensors. The described technique uses fluidic isolation by encasing the pressure sensor in a liquid-filled medical-grade polyurethane balloon; thus, isolating it from surrounding aqueous environment that is the major source of baseline drift. In-vitro tests using commercial micromachined piezoresistive pressure sensors show an average baseline drift of 0.006 cmH 2 O/day (0.13 mmHg/month) for over 100 days of saline soak test, as compared to 0.101 cmH 2 O/day (2.23 mmHg/month) for a non-fluidic-isolated one soaked for 18 days. To our knowledge, this is the lowest reported drift for an implantable pressure sensor.

Patients with pulmonary insufficiency due to scleroderma have long been considered suboptimal candidates for lung transplantation. This has been supported by small single-center experiences that did not reflect the entire U.S. experience. We sought to evaluate the outcome of patients with scleroderma who underwent lung transplantation. We conducted a retrospective review of 47 patients with scleroderma who underwent lung transplantation at 23 U.S. centers between 1987 and 2004 and were reported to the United Network for Organ Sharing. Women constituted 57% of the patients. The mean age was 46 years. Twenty-seven patients received single lung transplants (57%), and the remaining received double lung transplants. The mean cold ischemia time was 4.1 hours. There were 7 early deaths (or =30 days) and 17 late deaths (30 days). The causes of early death were primary graft failure and a cardiac event in two patients each and bacterial infection and stroke in one patient each. Late mortality was due to infection in seven patients, respiratory failure in three, malignancy in two, and multisystem organ failure, rejection, pulmonary hypertension, and a cardiac event in one patient each. The causes of early and late death were not recorded for two patients. One patient received a second transplant owing to graft failure of the first. Twenty-three patients (49%) were alive at a mean follow-up of 24 months. The Kaplan-Meier 1- and 3-year survival rates were 67.6% and 45.9% respectively, which are not significantly different from those of 10,070 patients given transplants for other lung conditions during the same period (75.5% and 58.8% respectively, P = 0.25). Donor gender, recipient's age, and type of transplant did not affect survival. In carefully selected patients with scleroderma who have end-stage lung disease, lung transplantation is a valid life-saving therapeutic option. Available data suggest acceptable short-term morbidity and mortality and a long-term survival similar to that of patients given transplants for other lung conditions.

Robot-assisted sacral colpopexy (RASC) utilization trends and influencing factors were examined. RASCs were compared with nonrobotic vaginal suspension procedures (non-RASC) used to treat patients with vaginal prolapse. Hospital costs associated with each approach were also examined. The presence of certain factors may predict increased use of RASC.The National (Nationwide) Inpatient Sample database was queried from 2009 to 2011 to identify patients undergoing RASC and non-RASC. Multivariable logistic regression was used to evaluate variables associated with RASC utilization, adjusting for age, comorbidities, concurrent procedures, hospital region, primary payer, and year. Multiple linear regression was used to evaluate variables associated with hospital costs when adjusting for operative approach, concurrent procedures, comorbidities, presence of complications, hospital region, and year.Of the 125,869 patients who underwent vaginal vault suspension of any type, 14,601 (12%) were RASC. Total in-hospital complication rates were similar between RASC and non-RASC (8% RASC, 7% non-RASC, P=0.360). The proportion of patients undergoing RASC increased throughout the study period (odds ratio [OR] 1.58, P0.001), with this increase being most pronounced in the South (OR 2.22, P0.001). Fifty-four percent of RASC patients vs 48% of non-RASC patients underwent concurrent hysterectomy (P=0.007). Patients with private insurance (OR 1.73, P=0.001) or Medicare (OR 1.43, P=0.033) as their primary payer were at significantly increased odds of RASC compared with Medicaid patients, and private insurance was associated with increased reimbursement. On multiple linear regression, RASC was independently associated with a $4825 increase in hospital costs (95% confidence interval $4161-$5490, P0.001). There were independent regional differences in cost associated with vaginal suspension, with the West being the most expensive (P0.001).While RASC utilization increased over the study period as a treatment option for vaginal prolapse, the majority of vaginal suspension procedures were still performed via non-RASC methods. RASC was associated with equivalent complications yet significantly higher costs.

Monitoring of bladder pressure, known as cystometry, is a key diagnostic tool in urodynamic studies of patients that exhibit lower urinary tract symptoms. Over the past few years, there has been an increased interest in ambulatory urodynamics due to the increased convenience and more realistic monitoring environment. This paper presents an ultra-low power implantable wireless platform, UP-Link, for long-term ambulatory bladder pressure monitoring. The proposed platform, which is built using off-the-shelf components and uses the MICS (Medical Implant Communication Service) radio frequency band for communication, enables more cost-effective and rapid development compared to existing ASIC-based solutions. The UP-Link platform is powered by two coin cell batteries with a total capacity of 560mAh and has an estimated battery life of several months to years. Results obtained through in vitro experiments demonstrate that the pressure data measured using UP-Link shows excellent agreement (0.995 using the intraclass correlation coefficient method) with measurements obtained using a commercial pressure gauge. An accelerated battery-life test was also performed, the results of which validate our lifetime estimates. The longevity of the UPLink platform enables ambulatory urodynamic studies at much longer time scales than current practice.

A 23-year-old female was involved in a motor vehicle collision with multiple injuries, including a right acetabular fracture, but no pelvic fracture. Urology consultation was obtained due to difficulty placing a urethral catheter. Examination revealed a longitudinal urethral tear with vaginal laceration extending 2 cm from the urethral meatus proximally toward the bladder neck. The longitudinal urethral tear was repaired primarily. Traumatic female urethral injury in the absence of a pelvic fracture is an exceedingly rare occurrence.

A 10-year-old boy presents with severe abdominal pain and urinary urgency. He denies any dysuria, hematuria, frequency, meatal spotting, penile discharge, or incontinence. He has had no recent viral infections or fevers and he denies any history of perineal trauma. He has no significant medical or surgical past medical history. Three days earlier, he was seen at a local hospital with a 3-day history of increasing difficulty with voiding, including straining to void and incomplete bladder emptying. A bladder scan revealed a full bladder after he voided. Therefore, an 8-French catheter was placed and he was told to return in 3 days for a voiding trial. He failed the voiding trial, and personnel at the local hospital were unable to replace the catheter. He was referred to our institution for further management. Physical examination reveals normal Sexual Maturity Rating stage 1 genitalia and a palpable bladder. He does not have any sacral dimples. Efforts to pass a 5-French feeding tube through the urethra also fail. Additional history and an imaging procedure lead to the diagnosis. The neurology consultant examines a 2-year-old boy in the outpatient clinic for “passing-out seizures.” His mother indicates that, in response to loud sounds, her otherwise healthy child experiences episodes of generalized, nonrhythmic, tonic muscle contractions characterized by “stiffness and back-arching,” collapse, and apnea. The episodes last 30 to 45 seconds, and in a typical day, the boy experiences three to four events. No other family members experience similar bouts. Findings on ECG, echocardiography, and 23-hour cardiac monitoring are unremarkable. Physical examination reveals an alert toddler who interacts appropriately with his mother and has no obvious signs of sensory or motor deficit. To evaluate the events, the child is admitted to the epilepsy monitoring unit. Examination of the electroencephalogram (EEG) reveals normal background rhythm. During the …

Patients with neurogenic disorders and voiding dysfunction have been reported to respond poorly to sacral neuromodulation. We report on our experience in treating voiding symptoms with sacral neuromodulation after spinal surgery. The medical charts of patients evaluated for sacral neuromodulation from 2000–2008 were retrospectively reviewed. Indications, need for explantation, and clinical success (>50% symptom improvement) were recorded. The cohort of patients who had undergone prior spinal surgery was compared to patients with no history of spinal surgery or neurological disease. Thirty-two patients with a history of spinal surgery and 136 with no history of neurologic disease underwent sacral neuromodulation testing. Twenty men and women (62.5%) from the spinal surgery group ultimately underwent permanent implantation. Seventeen of the 32 patients were diagnosed with urge incontinence, of whom 52.9% reported a successful outcome at a mean of 2.3 years of follow-up, compared to an 80.3% success rate in patients with no history of spinal surgery (p= 0.018). Sixteen of 32 carried a diagnosis of urgency/frequency with 62.5% success at last follow-up, compared 73.9% (p= 0.35) of those without a history of spinal surgery or neurological disease. Thirteen of 32 patients diagnosed with urinary retention experienced a 61.5% long-term success rate, compared with 63.6% for those without spinal surgery and urinary retention. Six of 20 (30.0%) in the spinal surgery group were explanted at a mean time of 2.9 years, compared with 27 of 102 (26.5%) of the non-neurologic patients. Clinical success can be achieved using sacral neuromodulation in patients with voiding dysfunction and a history of spinal surgery; however, those with urge incontinence are less likely to report significant improvement.

Prostatitis ranges from a straightforward clinical entity in its acute form to a complex, debilitating condition when chronic. It is often a source of frustration for the treating physician and patient. There are four classifications of prostatitis: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic. Diagnosis of acute and chronic bacterial prostatitis is primarily based on history, physical examination, urine culture, and urine specimen testing pre- and post-prostatic massage. The differential diagnosis of prostatitis includes acute cystitis, benign prostatic hyperplasia, urinary tract stones, bladder cancer, prostatic abscess, enterovesical fistula, and foreign body within the urinary tract. The mainstay of therapy is an antimicrobial regimen. Chronic pelvic pain syndrome is a more challenging entity, in part because its pathology is poorly understood. Diagnosis is often based on exclusion of other urologic conditions (e.g., voiding dysfunction, bladder cancer) in association with its presentation. Commonly used medications include antimicrobials, alpha blockers, and anti-inflammatory agents, but the effectiveness of these agents has not been supported in clinical trials. Small studies provide limited support for the use of nonpharmacologic modalities. Asymptomatic prostatitis is an incidental finding in a patient being evaluated for other urologic problems.

We present our long-term experience with sacral neuromodulation devices placed in patients with painful bladder syndrome to determine whether the benefit decreases over time.Between January 2000 and July 2004, 32 women and 7 men with interstitial cystitis/painful bladder syndrome in whom previous conventional therapy failed underwent sacral neuromodulation test stimulation. Before 2003 a percutaneous test lead was placed in the clinic setting. After 2003 a quadripolar permanent lead was placed in the operating room. Permanent generators were implanted if the patient had more than 50% relief from the presenting complaint, which was defined as urinary or pelvic pain, urgency, or urinary frequency. Long-term outcomes included battery depletion, device malfunction, infection or loss of benefit as well as any change in need for medications.Of 39 patients 22 went from test stimulation to permanent generator implantation. There were significant differences in short-term but not long-term outcomes between the 2 methods of test stimulation. Of 33 patients undergoing percutaneous nerve evaluation 13 (39.4%) met the criteria for permanent generator implantation, while 9 of 11 (81.8%) evaluated with the quadripolar lead met these criteria (p = 0.015). Long-term success between the groups was similar at 92.3% (12 of 13) vs 77.8% (7 of 9) (p = 0.329) during an average followup of 59.9 months. Eleven (50.0%) devices required explantation. Of 22 patients 3 (13.6%) lost benefit over time.These patients appear to respond best to permanent quadripolar lead placement but long-term results do not appear to be independently affected by the method of test stimulation. Loss of benefit over time is not common.

The kidney has both afferent (sensory) and efferent (sympathetic) nerves that can influence renal function. Renal innervation has been shown to play a role in the pathogenesis of many forms of hypertension. Hypertension and flank pain are common clinical manifestations of autosomal dominant (AD) polycystic kidney disease (PKD). We hypothesize that renal innervation contributes to the hypertension and progression of cystic change in rodent PKD. In the present study, the contribution of renal innervation to hypertension and progression of renal histopathology and dysfunction was assessed in male Han:SPRD-Cy/+ rats with ADPKD. At 4 weeks of age, male offspring from crosses of heterozygotes (Cy/+) were randomized into either 1) bilateral surgical renal denervation, 2) surgical sham denervation control, or 3) nonoperated control groups. A midline laparotomy was performed to allow the renal denervation (i.e., physical stripping of the nerves and painting the artery with phenol/alcohol). Blood pressure (tail cuff method), renal function (BUN) and histology were assessed at 8 weeks of age. Bilateral renal denervation reduced the cystic kidney size, cyst volume density, systolic blood pressure, and improved renal function (BUN) as compared with nonoperated controls. Operated control cystic rats had kidney weights, cyst volume densities, systolic blood pressures, and plasma BUN levels that were intermediate between those in the denervated animals and the nonoperated controls. The denervated group had a reduced systolic blood pressure compared with the operated control animals, indicating that the renal innervations was a major contributor to the hypertension in this model of ADPKD. Renal denervation was efficacious in reducing some pathology, including hypertension, renal enlargement, and cystic pathology. However, sham operation also affected the cystic disease but to a lesser extent. We hypothesize that the amelioration of hypertension in Cy/+ rats was due to the effects of renal denervation on the renin angiotensin system.